death in thef2004 death in the 05 line of duty... front of structure page 2 residential basement...

Residential Basement Fire Claims the Life of Career Lieutenant -Pennsylvania

January 5, 2005A summary of a NIOSH fire fighter fatality investigation

SUMMARYOn January 9, 2004, a 45-year-old male careerlieutenant (the victim) sustained serious injuries afterhe partially fell through the first floor while fighting aresidential basement fire. The victim was among thefirst on the scene, and he reported light smoke comingfrom a two-story, middle row town home. The victimentered the structure without his self containedbreathing apparatus (SCBA) to investigate, andreported to the Incident Commander (IC) that it wasa basement fire. The victim exited the structure toassist his crew in advancing a 1 3/4-inch hoselineinto the structure through the front door of the firstfloor. The victim’s crew protected the first floor andlooked for fire extension as another crew attackedthe fire through a rear entrance into the basement.The victim exited the structure a second time,presumably for air, and spoke to another memberwho was conducting ventilation. The victim wentback into the structure and was trapped on his thirdattempt to exit when he partially fell through the floor.

Rescue crews found and removed the victim withinminutes and he was transported to an area hospitalwhere he died from his injuries seven days later.

NIOSH investigators concluded that, to minimize therisk of similar occurrences, fire departments should:

• require, and all officers should enforce therequirement, that all fire fighters wear theirSCBAs whenever there is a chance theymight be exposed to a toxic or oxygen-deficient atmosphere, including during theinitial assessment

• ensure fire fighters are trained to recognizethe danger of operating above a fire

• ensure that team continuity is maintainedwith two or more fire fighters per team

INTRODUCTIONOn January 9, 2004, a 45-year-old male careerlieutenant (the victim) sustained serious injuries afterhe partially fell through the first floor while fighting a

The Fire Fighter Fatality Investigation and PreventionProgram is conducted by the National Institute forOccupational Safety and Health (NIOSH). The purpose ofthe program is to determine factors that cause or contributeto fire fighter deaths suffered in the line of duty.Identification of causal and contributing factors enableresearchers and safety specialists to develop strategies forpreventing future similar incidents. The program does notseek to determine fault or place blame on fire departmentsor individual fire fighters. To request additional copies ofthis report (specify the case number shown in the shieldabove), other fatality investigation reports, or furtherinformation, visit the Program Website at

www.cdc.gov/niosh/firehome.htmlor call toll free 1-800-35-NIOSH

Fire Fighter Fatality Investigation and Prevention Program

F2004 Death in the line of duty...05

Front of Structure

Residential Basement Fire Claims the Life of Career Lieutenant - Pennsylvania

Investigative Report #F2004-05Fatality Assessment and Control Evaluation

Fire Fighter Fatality Investigation And Prevention Program

residential basement fire. The victim died from theseinjuries seven days later. On January 16, 2004, theU.S. Fire Administration (USFA) notified theNational Institute for Occupational Safety and Health(NIOSH) of the fatality. On March 10, 2004 throughMarch 12, 2004, two Safety and OccupationalHealth Specialists from the NIOSH Division of SafetyResearch investigated the incident. Meetings wereconducted with the Fire Commissioner, the FireDepartment’s Operations Officer, representativesfrom the Fire Marshal’s Office, and representativesfrom the International Association of Fire Fighters.Interviews were conducted with officers and firefighters who were at the incident scene. The NIOSHinvestigators reviewed the department’s standardoperating procedures (SOPs), the fire marshal’sreport, victim’s training records, and drawings of thebuilding. The incident site was visited andphotographed.

DepartmentThe career department involved in this incident iscomprised of 2,300 uniformed fire fighters. Thedepartment serves a population of approximately 1.7million residents in a geographic area of about 130square miles.

TrainingThe fire department provides all new recruits with a15-week training conducted at the city’s FireAcademy. The victim had more than 14 years ofexperience and had successfully completed numeroustraining courses such as: Fire Fighter I and II, FireInstructor I, Incident Command System, HazardousMaterials Operations, Rapid Intervention, and SCBAorientation.

Building InformationThe structure was a two-story, middle row, 16ft. x45ft. brick dwelling. It was built in the 1930’s, prior

to any existing building codes, and had a full basementwith a ground level entrance in the rear of the structure.The flooring system where the incident occurredconsisted of a parquet wood floor approximately3/8-inch thick covering a wood plank sub-floorapproximately 3-inches wide by 3/4-inch thick nailedto 2 1/2-inch by 8-inch floor joists that were 16-inches on center. The residence was equipped withsmoke detectors.

EquipmentAdditional units were dispatched; however, onlythose units directly involved in operations precedingthe fatal event are discussed in the investigationsection of this report.Engine 72 (Victim, driver/operator, 2 fire fighters)Engine 51 (Officer, driver/operator, 2 fire fighters)Ladder 29 (Officer, driver/operator, 3 fire fighters)Ladder 22 (Officer, driver/operator, 3 fire fighters)Ladder 8/Rapid Intervention Team (Officer, driver/operator, 3 fire fighters)B2 (Battalion Chief 2, Chief’s Aide)

INVESTIGATIONOn January 9, 2004, a 45-year-old male careerlieutenant (the victim) sustained serious injuries afterhe partially fell through the first floor while fighting aresidential basement fire. At 0626 hours, Engine 72(E72), Engine 51 (E51), Ladder 29 (L29), Ladder22 (L22), and Battalion Chief 2 (IC) were dispatchedto a residential dwelling for a reported fire. At 0629hours, E72 arrived on the scene and the victimreported light smoke coming from a two-story,middle row, 16ft. x 45ft. dwelling (see Cover Photo).The victim entered the structure without his selfcontained breathing apparatus (SCBA) to investigate,and reported to the Incident Commander (IC) that itwas a basement fire. The victim exited the structureand placed E72 and L29 in service at the front of thestructure. Two fire fighters and the victim from E72advanced a 1 3/4-inch hoseline into the structure (see




Diagram 1), while L29 placed ground ladders to thesecond floor to conduct ventilation. One of the firefighters informed the victim that the floor was veryhot and physically weakened or “spongy” as theyadvanced the handline. The victim notified the ICthat they had a basement fire, and at approximately0630 hours, the IC arrived on scene and placed anadditional engine and ladder into service.

E51 and L22 were operating at the rear of thestructure with the IC. L22 was assigned search andrescue, while E51 made entry into the basementthrough a door at ground level (see Photo 1). Entrywas impeded approximately 10 feet inside thebasement door due to an old appliance and debriswhich was stacked about five feet high over the entirebasement floor (see Diagram 2).

E51 informed the IC that they were working onclearing debris to access the fire. The IC called thevictim to inform him that E51 would attack the firefrom the basement level. The Captain from L29responded for the victim and confirmed the order at0635 hours. Note: The Captain and the victimwere talking on the front porch of the structureafter the victim exited the structure for the secondtime. The victim did not have his SCBA on andwas leaning over the banister attempting to catchhis breath. The Captain told the victim to get offof the porch and get some fresh air. The victimwent back inside a third time as the Captain wasworking on ventilating the basement. The Captainfrom L29 then radioed his crew to tell them to ventthe porch floor after they finished venting the roof.Note: The porch floor is also the ceiling over thenorth section of the basement (see Diagram 2).

At 0641 hours, the IC called the Captain fromLadder 29 and requested that he take command ofthe front of the structure and to keep him posted onthe fire conditions and ventilation of the front of the

structure. The IC stated that E51 was makingprogress on the fire at this time. The victim, two ofhis fire fighters, and a fire fighter from L29 werestationed at the door of the stairs leading to thebasement with a 1 3/4-inch handline awaitinginstructions. They were on their hands and knees toavoid the heat and smoke in near zero visibilityconditions. At 0642 hours, the IC called the victimto tell him to hold his ground on the first floor andthat E51 was attacking the fire from the basement.The IC wanted the victim to guard against fireextension on the first floor and to attempt hydraulicventilation by flowing water through a window onthe first floor to draw the smoke out of the window.At 0643 hours, the victim responded “That’saffirmative, we can do that.” The victim turnedaround to exit the first floor and tripped over thehand of one of his fire fighters and stumbled towardsthe front door. Fourteen seconds after his lasttransmission, the victim keyed his radio for 4 secondswithout speaking. Note: The victim did not makeit out of the structure. It is believed that thevictim’s foot fell through the floor at this time(see Photos 2 and 3).

After the crew from E72 did not hear from the victimfor a couple of minutes, one fire fighter started tocrawl towards the front door to check for the victim.As he was nearing the threshold to the living roomfrom the dining room, his hand penetrated throughthe floor and the fire lit up right in front of him. Thecrew put water on the fire and radioed for the victimat 0646 hours with no response. The crew’s exitpath through the front door was cut off by the fire.They turned around, went down the basement stairs,and exited through the basement door in the rear ofthe structure. Upon exiting, the fire fighter from L29with E72 radioed an “Urgent” message then followedup with the IC at 0650 hours that the crew from thefirst floor exited, but that they didn’t know the locationof the victim. The IC deployed the Rapid




Intervention Team (RIT) at 0651 hours to search forthe victim. The victim was found by a member ofthe RIT and a fire fighter from L29 face down withone of his legs through a hole in the floor at 0701hours (see Photo 4). Within a few minutes the victimwas removed and transported to an area hospitalwhere he died seven days later from his injuries.

CAUSE OF DEATHThe medical examiner lists the cause of death assmoke and soot inhalation and thermal burns.

RECOMMENDATIONS/DISCUSSIONSRecommendation #1: Fire departments shouldrequire, and all officers should enforce therequirement, that all fire fighters wear theirSCBAs whenever there is a chance they mightbe exposed to a toxic or oxygen-deficientatmosphere, including during the initialassessment.1-5

Discussion: Since carbon monoxide (CO) is givenoff in varying quantities during all fires, and other toxicmaterials are typically present, it is paramount thatofficers enforce and fire fighters follow thedepartment’s guidelines for the wearing of masks atstructure fires. In this incident, a number of firefighters reported not wearing their masks inside thestructure even while encountering moderate smokeconditions. Far more fire deaths occur from carbonmonoxide than from any other toxic product ofcombustion. This colorless, odorless gas is presentin every fire. The poorer the ventilation and the moreinefficient the burning, the greater the quantity ofcarbon monoxide formed.

Table 1 lists the toxic effects of carbon monoxide.Concentrations of carbon monoxide in air above fivehundredths of one percent (0.05 percent) or 500parts per million can be dangerous. When the level

is more than 1 percent, unconsciousness and deathcan occur without physiological signs. Therefore,the signs and symptoms outlined in Table 1 are notgood indicators of safety.

The toxicity of carbon monoxide (CO) varies withthe length of exposure, the concentration, breathingand heart rate. CO causes tissue hypoxia (low oxygencontent) by preventing the blood from carryingsufficient oxygen. CO combines much more readilywith the oxygen-carrying sites on the hemoglobinmolecule than oxygen itself. The carboxyhemoglobinthus formed is unavailable to carry oxygen. Toxicityof CO varies with the percent carboxyhemoglobinin the blood. Reactions to CO poisoning vary withthe individual and include headache, vertigo, difficultybreathing, confusion, convulsions, and coma. A 1percent concentration of carbon monoxide in a roomwill cause a 50 percent level of carboxyhemoglobinin the blood stream in 2 1/2 to 7 minutes. A 5 percentconcentration can elevate the carboxyhemoglobinlevel to 50 percent in only 30 to 90 seconds. Becausethe newly formed carboxyhemoglobin may betraveling throughout the body, a person previouslyexposed to a high level of carbon monoxide mayreact later. Carboxyhemoglobin levels greater than55 percent usually are fatal; 40 percent levels areassociated with collapse and syncope (a faint); at 15percent to 25 percent headache and nausea may bepresent. If fire fighters are potentially affected bycarbon monoxide, they should not be allowed tocontinue with firefighting operations. If fire fighterssuspect they have been exposed to carbonmonoxide, they should immediately notify their officeror the IC. In this incident, the victim entered thestructure to conduct an initial assessment andcontinued to operate without a SCBA. His exposureto carbon monoxide started when he first enteredthe structure and may have affected his decisionmaking process throughout the incident.




Recommendation #2: Fire departments shouldensure fire fighters are trained to recognize thedanger of operating above a fire.6

The danger of being trapped above a fire is greatlyinfluenced by the construction of the burning building.Of the five basic building construction types (fireresistive, noncombustible, ordinary construction,heavy timber, and wood frame) the greatest dangerto a fire fighter who must operate above the fire isposed by wood-frame construction. Vertical firespread is more rapid in this type of structure. Flamesmay spread vertically and trap fire fighters operating

above the fire, in four ways: up the interior stairs,through windows (autoexposure), within concealedspaces, or up the combustible exterior siding.Extreme caution must be used to determine if thestructural stability of the flooring system is adequateto facilitate the operations. In this incident, the floorwas noticeably weakened as the victim’s crewadvanced the initial handline, indicating that the floorwas not structurally sound to support operations onthe first floor above the fire. As soon as fire fightersbecome aware of structural instability, they shouldimmediately exit the structure and notify the IC.

Carbon

Monoxide (CO)(ppm)

Carbon Monoxide in air (percent) Symptoms

100 0.01 No symptoms-no damage .

200 0.02 Mild headache; few other symptoms.

400 0.04 Headache after 1 to 2 hours.

800 0.08 Headaches after 45 minutes; nausea, collapse, and unconsciousness after 2 hours.

1,000 0.1 Dangerous; unconscious after 1 hour.

1,600 0.16 Headache, dizziness, nausea after 20 minutes.

3,200 0.32 Headache, dizziness, nausea after 5 to 10 minutes; unconsciousness after 30 minutes.

6,400 0.64 Headache, dizziness, nausea after 1 to 2 minutes; unconsciousness after 10 to 15 minutes.

12,800 1.28 Immediate unconsciousness, danger of death in 1 to 3 minutes.

Table 1. Toxic Effects of Carbon Monoxide




Recommendation#3: Fire departments shouldensure that team continuity is maintained withtwo or more fire fighters per team.3,7

Discussion: Each fire fighter must be assigned to ateam of two or more and be given specificassignments to help reduce the chance of injuries.Team continuity relies on some very important keyfactors: knowing who is on your team and the teamleader, staying within visual contact at all times (ifvisibility is obscured then teams should remain withintouch or voice contact distance of each other),communicating your needs and observations to theteam leader, rotating to rehab and staging as a team,and watching your team members (practice a strong“buddy-care” approach). These key factors help toreduce serious injury or even death resulting fromthe risks involved in fire fighting operations byproviding personnel with the added safety net offellow team members. Company or crew membersshould enter and exit the environment together.

INVESTIGATOR INFORMATIONThis incident was investigated by Jay Tarley andVirginia Lutz, Safety and Occupational HealthSpecialists, Division of Safety Research, NIOSH.

REFERENCES1. NFPA [1997]. Fire protection handbook. 18th

ed. Quincy, MA: National Fire ProtectionAssociation.

2. Brunacini AV [1985]. Fire command. Quincy,MA: National Fire Protection Association.

3. International Fire Service Training Association.[1998]. Essentials of fire fighting. 4th ed.Stillwater, OK: Oklahoma State University.

4. NFPA [1997]. NFPA 1500, standard on firedepartment occupational safety and healthprograms. Quincy, MA: National Fire ProtectionAssociation.

5. International Fire Service Training Association[1995]. Essentials of fire fighting. 4th ed.Stillwater, OK: Fire Protection Publications,Oklahoma State University.

6. Dunn V [1999]. Command and control of firesand emergencies. Saddle Brook, NJ: FireEngineering Books and Videos, p.245

7. Fire Fighter’s Handbook [2000]. Essentials offire fighting and emergency response. New York:Delmar Publishers.




Photo 1. Rear of structure




Photo 2. Floor area consumed by fire




Photo 3. View from basement of floor area consumed by fire




LOCATION OF VICTIM

Photo 4. Living room floor




REAR OF STRUCTURE

FRONT OF STRUCTURE

N

PORCH

LIVING ROOM

DINING ROOM

KITCHEN

FIR

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PLA

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FLOOR AREA CONSUMED

BY FIRE

STAIRS TO 2nd FLOOR

STAIRS TO 2nd FLOOR

STAIRS TO BASEMENT

1 ¾ -INCH HANDLINE

VICTIM

Diagram 1. First floor aerial view layout




SHEDPILED CLOTHES &

DEBRIS THROUGHOUT

ROOM

FURNACE

FIRE LOCATION

DEBRIS THROUGHOUT

ROOM

DEBRIS THROUGHOUT

ROOM

NREAR OF STRUCTURE

FRONT OF STRUCTURE

AREA BELOW PORCH

APPLIANCE

1 ¾ -INCH HANDLINE

Diagram 2. Basement aerial view layout

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death in thef2004 death in the 05 line of duty... front of structure page 2 residential basement...

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